Ewing's sarcoma of kidney extending into IVC and RA: resection using modified cannulation strategy for CPB.

Ewing's sarcoma of the kidney is a rare tumor. Although renal carcinomas are known to involve the inferior cava, extension of the tumor up to the right atrium is not common. In the majority of cases when the tumor extends into the infrahepatic part of the inferior vena cava, it can be removed from the abdominal approach. Few patients require the use of cardiopulmonary bypass for removal of the tumor in the inferior vena cava and right atrium. The management of patients requiring resection of kidney tumors and right atrial mass is more complicated and requires a team approach consisting of oncosurgeons, cardiac surgeons, and cardiac anesthetists. The resection of the kidney tumor with a mass in the right atrium is usually done concomitantly. The cardiopulmonary bypass cannulation strategy needs to be modified in such cases.

Mitral valve replacement in patients of rheumatic heart disease associated with immune thrombocytopenia.

Immune thrombocytopenia in association with rheumatic heart disease is not commonly seen. Surgical management of rheumatic heart disease becomes more challenging in the presence of immune thrombocytopenia. The risk of complications increases manifold and judicious medical management before, during, and after surgery is imperative. We discuss two such cases, the complications we faced and the problems we anticipated before, and their prevention. Both patients were managed without using immunoglobulins or doing splenectomy. The literature on valve replacement in patients of immune thrombocytopenia and the implications of immune thrombocytopenia in the management of patients with rheumatic heart disease is also reviewed.

Vein of Giacomini can lead to the recurrence of varicosities after endovenous laser ablation of varicose veins.

Endovenous laser ablation is a commonly performed intervention in the treatment of varicose veins. The technique is generally safe and has low complication rates. A case of recurrent varicose veins that had undergone endovenous laser ablation multiple times is reported. The cause of recurrence, in this case, was the vein of Giacomini, the presence of which was probably missed at the time of initial intervention. This case highlights the importance of the vein of Giacomini in causing recurrent varicosities after laser ablation.

Large mediastinal/thoracic benign teratoma presenting with haemoptysis: Report of a case and review of the literature.

The mediastinal teratomas can grow to a large size before becoming symptomatic. The symptoms are usually due to the compression of adjacent structures. A computed tomographic scan of the chest is the investigation of choice for making a provisional diagnosis and planning for further management. Removal of large mediastinal/thoracic teratoma can be associated with various intraoperative and postoperative complications, which can be life-threatening sometimes. We operated on a patient with a large mediastinal mass extending into the right thoracic cavity up to the costo-phrenic angle. The postoperative period was eventful and required judicious intensive care. The patient eventually recovered with conservative treatment. A literature search was done on PubMed using the keywords benign mediastinal teratoma. Case series/original articles published in the last two decades, that is, after the year 2000, were evaluated. As per the review of the literature, the prevalence of benign mediastinal teratoma may be higher in eastern countries. Thoracoscopic surgery is the preferred modality except for cases with adhesions or infiltration into surrounding structures.

Excision of a giant lung bulla in a child: Repair of bronchial leaks using redundant bullous wall/membrane.

Large lung bullae are rare in children. We report a rare case of a large bulla in the right lung causing compression of the underlying lung with a shift of the mediastinum to the contralateral side. Excision of the bulla was done and a novel technique was used in the repair of bronchial air leakage sites with part of the bullous wall/membrane. The patient recovered well with re-expansion of the underlying collapsed lung.

Allergic bronchopulmonary aspergillosis in association with rheumatic heart disease: report of three cases.

Allergic bronchopulmonary aspergillosis is usually seen in patients with asthma or cystic fibrosis. Its association with rheumatic heart disease has not been adequately reported in literature. We report our experience of three cases who were diagnosed cases of rheumatic heart disease. Their symptomatology and clinical findings required further evaluation and investigations, which were suggestive of allergic bronchopulmonary aspergillosis. The patients were treated with steroids and/or antifungals before proceeding with the valve replacement.

Early and midterm patency of arteriovenous fistula for hemodialysis access using different techniques and their advantages and disadvantages.

This descriptive retrospective study was done to observe the different techniques of arteriovenous fistula creation for advantages and disadvantages, complications, and early and midterm patency. Fifty-three arteriovenous fistulas were created from September 2018 to August 2020 using four different techniques. Radio-cephalic arteriovenous fistula was usually the first option. Other techniques like brachio-cephalic arteriovenous fistula, radio-basilic arteriovenous fistula, and brachio-basilic arteriovenous fistula were used when the radio-cephalic fistula had thrombosed or could not be constructed due to small-sized cephalic vein in the forearm. The majority of patients (41 (77.35%)) underwent radio-cephalic fistula creation. Early patency was 38 (92.7%) in the radio-cephalic technique whereas it was 12 (100%) in the radio-basilic, brachio-cephalic, and brachio-basilic techniques combined. The midterm patency was 32 (78%) in the radio-cephalic technique, 5 (83%) in the brachio-cephalic technique, 3 (75%) in the radio-basilic technique, and 1 (50%) in the brachio-basilic technique. Radio-basilic and brachio-cephalic are alternative techniques for fistula creation after radio-cephalic depending upon the size of the basilic vein in the forearm or cephalic vein in the cubital fossa or arm. The radio-basilic technique may have advantages over the brachio-cephalic technique which need to be further evaluated. Proximal fistulas like brachio-basilic and brachio-cephalic are more commonly associated with limb edema.

Giant isolated iliac artery aneurysm with ipsilateral hydronephrosis treated with aneurysm resection and extra-anatomic bypass.

Isolated iliac artery aneurysms are rare and very rarely it may lead to hydronephrosis. The majority of uncomplicated iliac artery aneurysms can be managed with endovascular interventions but large complicated iliac artery aneurysms with compression on adjacent structures may require open surgery. We share our experience of a case of a large isolated iliac artery aneurysm with compression of the ureter probably leading to ureteric calculi and hydronephrosis on the ipsilateral side. The patient was managed with aneurysm resection and extra-anatomic bypass.

Ulnar-Basilic Arteriovenous Fistula for Hemodialysis Access: Utility as the "Second Procedure" after Radio Cephalic Fistula.

Objectives: As per standard guidelines, the recommended order of arteriovenous fistula (AVF) creation for hemodialysis (HD) access is radiocephalic (RC), followed by proximal elbow fistulas and arteriovenous graft. Although ulnar-basilic (UB) fistula has been an alternative to RC-AVF, still this procedure searches clear recommendations. We present here our experience on UB-AVF as the preferred "second procedure" instead of proximal fistula after the RC-AVF. Methods: Forty-two UB-AVF were created in nonfeasible and failed RC-AVF cases between 2016 and 2018. They were reviewed retrospectively and outcomes were compared with 480 RC-AVF constructed within the same period. Results: The primary patency at 18 months was 73.8%, 69.6% and mean maturation time was 33.7±6.6 days, 32.1±4.7 days for UB-AVF and RC-AVF respectively (p>0.05). Conclusion: Our altered order of preference enabled us to create all the first-time fistula in the distal forearm, providing all the advantages of distal fistula like RC-AVF and avoiding proximal fistula, improved patient convenience and short-term benefit. In an inference that may be used for references and needs support from a larger sample and longer duration study from other centers, UB-AVF may be considered as the second option after RC-AVF depending on the clinical scenario.

Successful patient outcome following surgery of carotid body tumor and temporary hypoglossal nerve dysfunction.

Carotid body tumors, also known as paragangliomas or chemodectomas, are rare tumors. They are mostly benign slow-growing tumors arising from neural crest cells, but can give rise to complications because of their location and close relation to carotid vessels and cranial nerves. A 40-year male patient diagnosed with a carotid body tumor is discussed along with a review of cranial nerve complications associated with the management of carotid body tumors. This case highlights the complete recovery after a temporary hypoglossal nerve deficit following surgery. Another important aspect is that syncopal attacks might occur in carotid body tumors and early surgery is required to prevent complications.

Intercostal muscle flap for repair of bronchopleural fistula.

A 50-year-old male patient, a known case of chronic obstructive pulmonary disease (COPD), presented with the features of bronchopleural fistula (BPF) on the right side for 1 month. The patient was a chronic smoker and did not give any history suggestive of pulmonary Koch's. The patient had sudden-onset breathlessness and chest pain 1 month before, which was diagnosed to be due to spontaneous pneumothorax. An intercostal drain was inserted but even after 1 month of all conservative measures, the lung remained collapsed and there was large air leak in the intercostal drain. Computed tomogram (CT) of the chest revealed collapsed and entrapped lung with surgical emphysema of the subcutaneous tissues due to rupture of the emphysematous bulla on the right side along with the presence of emphysematous bullae on the left upper lobe also. Surgical intervention in the form of decortication of entrapped lung and repair of the BPF with intercostal muscle flap was performed. The patient recovered well and was discharged after 10 days.

Management of a case of ruptured pseudoaneurysm and stenosis of femoral artery caused by femoral osteochondroma.

We present a rare case of ruptured pseudoaneurysm of distal femoral artery due to osteochondroma in a 21-year- old male. The patient was initially treated for osteochondroma as ruptured pseudoaneurysm was not suspected. Diagnosis of ruptured pseudoaneurysm could only be made intraoperatively when rent in the femoral artery was found along with surrounding hematoma and obstruction in the distal femoral artery. Patient underwent multiple surgeries (resection of osteochondroma and femoro-popliteal bypass) and recovered well with palpable pulsations in the operated limb.

Thoracic sympathectomy for peripheral vascular disease can lead to severe bronchospasm and excessive bronchial secretions.

A 57-year-old male patient suffering from Buerger's disease presented with pre-gangrenous changes in right foot and ischemic symptoms in right hand. Computed tomographic angiography revealed diffuse distal disease not suitable for vascular bypass and angioplasty. Right lumbar sympathectomy was done using a retroperitoneal approach followed 1 year later by right thoracic sympathectomy using a transaxillary approach. Postoperatively, the patient had severe bronchospasm and excessive secretions in the respiratory tract resistant to theophylline and sympathomimetic group of drugs and without any clinical, laboratory and radiological evidence of infection. The patient was started on anticholinergics in anticipation that sympathectomy might have lead to unopposed cholinergic activity and the symptoms improved rapidly. The patient recovered well and was discharged on 10(th) post-operative day.

Transthoracic repair of paraesophageal diaphragmatic hernia presenting with symptoms mimicking cardiac disease (chest pain and breathlessness).

We discuss a case of 60-year-old female patient, who presented with history of chest pain radiating to left shoulder, breathlessness and postprandial discomfort. Patient was initially suspected to be suffering from cardiac pathology and was evaluated accordingly. Upper gastrointestinal endoscopy also missed the findings of paraesophageal hernia as the gastroesophageal junction was at its normal position. Chest roentgenogram raised the suspicion of diaphragmatic hernia, computed tomogram of chest and abdomen was done later on and showed characteristic features of paraesophageal hernia. Patient underwent transthoracic repair of the paraesophageal hernia along with partial fundoplication and had complete relief from the symptoms after surgery.

Single-stage management of large pulmonary and hepatic hydatid cysts in pediatric age group: Report of two cases.

Two patients presented to us with very similar clinical and radiological presentation of huge hydatid cysts in the lung and liver. The first patient was an 11-year-old female child and the second one was a 9-year-old male child. The clinical features in both were breathlessness on exertion, pain abdomen, and abdominal distension. Chest Roentgenogram along with computed tomogram of the chest and abdomen revealed presence of thin-walled homogenous large cysts, one in the right lung and two in the liver, in both the cases. Although the liver cysts were of larger size and occupying most of the right lobe of the liver and part of the left lobe, liver function tests were normal. All three cysts were enucleated in the same sitting by a combined thoracic and abdominal approach (thoracotomy followed by laparotomy). After enucleation of the cyst, capitonnage of the cavity in the lung was done and the liver cavities were filled with omentum to prevent collection of fluid and abscess formation. Both patients recovered well, although the second patient required abdominal drain for a long period of 1 month for bile leakage which decreased gradually and eventually stopped.

Axillary artery injury caused by fracture of humerus neck and its repair using basilic vein graft.

Proximal humerus fractures are rarely associated with axillary artery injury. We present a case of a 59-year-old female who had fracture neck humerus along with absent pulsations in the left upper limb after blunt trauma. Computed tomographic angiogram revealed complete occlusion of the left axillary artery. Urgent surgical intervention was done in the form of fixation of fracture followed by exploration and repair of axillary artery. Axillary artery was contused and totally occluded by fractured edge of humerus. Repair of the axillary artery was done using basilic vein graft harvested through the same incision. Postprocedure pulsations were present in the upper limb.

Mesenteric Lymph Node Hamartoma (Castleman's Disease) in Association with Superior Mesenteric Arteriovenous Fistula.

We present a case of 21-year-old female patient with history of pain abdomen and abdominal distension. The patient also had oedema of the limbs, puffiness of the face, pallor and palpable mass in the abdomen. Ultrasonography of the abdomen and computed tomographic angiogram was done and it showed presence of vascular mass along with arteriovenous malformation in the mesentry of small gut between distal branches of superior mesenteric artery and vein. Surgical excision of the mass with ligation and division of the arteriovenous malformation was done through midline laparotomy. Histopathological examination was consistent with the diagnosis of Castleman's disease. The Patient recovered well and was discharged after seven days.

Isolated common iliac artery aneurysm: a rare entity.

Isolated aneurysms in iliac artery are not common. A 65-year-old male patient presented with complaints of pain abdomen, abdominal distension and history of hypertension, Clinical examination revealed pulsatile mass in the right iliac fossa extending upto paraumbilical region with palpable pulsations in all the limbs. Computed tomographic (CT) angiogram was done and it revealed large aneurysm of right common iliac artery. CT chest and abdomen did not reveal aneurysm in thoracic and abdominal aorta. As the size of aneurysm was large and there was risk of rupture, surgical intervention in the form of aneurysmorrhaphy was done. Open surgery was done as the anatomy was not favourable for endovascular intervention. Aneurysmorrhapy was done using 6mm ringed Poly Tetra Fluoro Ethylene graft. Patient recovered well and was discharged after 10 days.